4 reasons why doctors should be outraged

4 reasons why doctors should be outraged

Outrage #1: Wasting time of skilled caregivers. Everyday skilled nurses and physicians’ assistants waste hours of time on the telephone either getting approval for medications that we prescribe for our patients or trying to fight a rejection for a medication we requested.

Outrage #2: Choosing a medication for cost, not effectiveness. A child cannot breathe because the acid and other nasty stomach contents come up from the stomach and inflame the airways without the right treatment. Although many of them might respond to one “preferred” drug, not all of them do. And, guess what? There is another “non-preferred” drug to which more of them will respond, but it is not allowed as a first line treatment, even in this critical airway situation. When there is an airway problem and the infant is choking, coughing, turning blue and not sleeping, or the airway is becoming progressively narrower, wouldn’t you want your child to have the medication that works more often? I know I would. The insurance companies call their approach “best practices” because most, but not more, might respond.

Outrage #3: Pretending we are giving care when we are not. So the one “preferred” (i.e. less expensive) medication also tastes really nasty. Many kids won’t take it at all no matter what flavor is used. So then families are told to mix it with their formula or juice or some other food and this dilutes its effects because it won’t work in that preparation.

Outrage #4: Pretending that patient diversity doesn’t exist. Different people respond to medication differently (? pharmaco-genetics). You know that’s true just from the way some of us fall asleep after one dose of Benadryl and others of us don’t get knocked out even with a whopping dose of morphine. We are in a real quandary when we have to fight (sometimes for weeks or months) to try another medication because the one we are allowed (first tier) doesn’t work. And then on the second or third tier, the family cannot afford it, doesn’t get the medication, and the child might go untreated. We have wasted money, time and have put the child in harm’s way.

Friends, I am not making this up. And the problem is going to get worse. Why? Because there are some with influence who really believe (incorrectly) that there are “experts” who know the right thing to do for an individual patient, whom they have never met. Well, they don’t. Each patient has a unique set of variables that requires a lot of thought before prescribing occurs. I have just named a few.

This misguided approach to patient care is much more eloquently discussed by Pamela Hartzband, MD and Jerome Groopman, MD in an editorial in the Wall Street Journal. I was so pleased to see that these two brilliant Harvard minds (wife and husband) have continued to chip away at the myth that there are such things as “best practices” or that “expert opinion” will result in the best care for all.

In my almost 10 year tenure as director of the Center for Pediatric Quality at the Children’s Hospital, I firmly resisted even using the term “best practices,” because I truly believed that there were only “better practices.” What we think is best today would and should be replaced by what is better tomorrow. That is what makes medicine challenging and what creates the forward movement of innovation. We have benefited from the explosion of treatment options for people who didn’t get treated 30 years ago because they were developmentally disabled or too old to undergo an operation or for whom the technology did not exist.

Yes, I am angry about this. Very angry and very frustrated. I am tired of being told what medications to use, what tests I can order and even what surgeries to perform. I am “appealing” to one insurance company to be paid for an operation they said was not proven effective in children. Were they faced with the anatomy that I encountered and knew was the cause of the problem and required a different operation than planned? Another has denied payment for an assistant surgeon which I needed because we performed a difficult airway case!

Should I have risked the child’s airway without another pair of skilled eyes and hands? And recently another applied criteria for tonsillectomy (which were outdated and wrong) and said the kid didn’t need it because my charting was inadequate. In every instance I know my judgment was correct, but their “expert panel” who might reads an article but has not been with this patient, comes up with a sweeping policy and applies it to all of the patients. It’s a joke that’s not funny.

So who needs doctors? Increasingly insurance companies and the government tell us what is best for our patients? That is what is happening. It is making me really angry. What about you?

Linda Brodsky is a pediatric surgeon who blogs at The Brodsky Blog.  She is founder of Women MD Resources.

Image credit: Shutterstock.com

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  • chrliechaz

    I appreciate you addressing the fact that patients need customized care. I have spent an immense amount of time negotiating my medication needs due to insurance tightropes.

    • LBENT

      Personalized medicine is the only way to practice. I agree with you completely.

      • Sue McIntire

        So what’s your opinion on single payer? Wouldn’t that be a solution to get back to personalized medicine?

        • LBENT

          No, single payer is the same as government controlled. I work with the government (medicaid) and they are the least interested in patients. I have very sick kids who cannot get the meds they need.

  • http://twitter.com/LisaGemini LisaGemini

    I am sorry to say it but I foresee this getting worse under Obamacare. What do bureaucrats in Washington know about health care? What if they decide not to treat an 80-year-old with lung cancer? Too many unresolved questions and a whopping number of doctors are leaving the profession. Rural areas will face shortages. How will that improve survival rates?

    • John Feehan

      You are of course correct. In addition to the reasons you suggest another reason it will be worse is that government bureaucrats act under the authority of law.

  • http://www.facebook.com/people/Rita-Chobanian-Swisher/1125771124 Rita Chobanian Swisher

    I am so proud of you for writing this. Please continue to speak up.

    • LBENT

      thank you

  • civisisus

    Dr. Brodsky has somehow forgotten to mention the grants she has routinely received from Armour, Aventis, Daiichi, Ross, and other pharma cos over the years. But of course they could not possibly have ever influenced her opinion on these matters….http://www.lindabrodskymd.com/about/pdf/Linda-CV-2-20-09.pdf

    There are plenty of things worthy of debating regarding the systematization of a profession that has positively psychotically neglected for generations doing inconvenient things like gathering broad-scale empirical data on whether what said professionals are doing actually benefits those for whose benefit it is presumably being done.

    Being angry that initiatives are beginning to address this long-neglected reality, and that they, too, are prone to clumsy design and mis-steps is churlish. And glibly zeroing on pharmaceutical dispensing protocols to the exclusion of larger issues, while conveniently neglecting to mention one’s own conflicts of interest, is, well, make of it what you will.

    • brian

      a swing…. and he completely misses the point. oh well…..

      • khmd

        Dr. Brodsky was going to receive those grants whether or not she wrote this article.
        Maybe the extra income was needed just to keep her practice alive.
        We have to get creative to find other ways to generate income because the 50 cents on the dollar the AMA has negotiated “on our behalf” is not going to keep our practices alive without other types of supplementation. Dr’s are treating varicose veins, wrinkles, unwanted hair with increasing frequency. Do you think this was our dream when we were applying to medical school?
        I don’t blame her one bit for speaking.
        Doctors don’t even have a voice to campaign for their own interests. It’s laughable to suggest that we think we have the power to make enough of a difference to impact the stock of pharmaceutical companies.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      The fact that Dr Brodsky was not asked for her professional relationships or potential conflicts of interest when she wrote this article does not detract from the fact that she is absolutely right on and correct.
      I have older patient with chronic mulitsystem disease who see multiple physicians by choice and due to their mobility may actually have physician teams in more than one area of the world. When you find a recipe of medicines that work and do not interact and then receive an email or phone call that their new insurance plan would like to change the medicines for cost reasons only it creates problems in many cases. Everything from the pill capsule constituents to nation and location of production of the generic product can effect its absorption, effectiveness and control of a chronic condition. The insurance company demanding the change never tells the customer or patient this fact. They just make the Coke to Pepsi analogy not the true risks and benefits which to most of us are really an unknown when the change is made

    • LBENT

      My grants, which also include NIH grants, and some of which are educational grants, were all done with our protocols, and for which we owned the data so the companies had no say on how these were reported. We honestly tried to test what we hoped would be more effective treatments. Sometimes they were, and sometimes they were not (if you bothered to read the publications.

      Be that as it may, that has nothing to do with the terrible waste of time I have encountered in over 30 years of busy practice as a physician and surgeon. People don’t fit into protocols. And even the best designed randomized controlled trials leave out most people because of strict study entry criteria.

      These initiatives do not address any reality other than insurance companies keeping down cost. Keeping down cost is important but not at the risk of ineffective or even harmful treatments.

  • http://www.facebook.com/profile.php?id=1546088532 George Wilson

    As a PACU nurse I work with a lot of very experienced and talented physicians. I’ve been pleased when I’ve called to ask for a specific medication or treatment and received the order. However, I’ve learned more and grown when my request has been replaced with an alternative that comes from the physician’s experience and/or in depth knowledge of the patient’s systems and comorbidities. Physicians in the trenches consider much more than what could ever be published in government guidelines or regulations.

  • Mahesh Jain

    It is true that practice of medicine requires holistic approach and a doctor has to input all his cumulative experience behind each and every patient to customize and optimize treatment for him. No judge, legislator or bureaucrat can ever be competent to interfere in a doctor’s jurisdiction, particularly in areas with shades of grey. Only the treating doctor can be the best judge, whether non-doctors like it or not. However it is also true that cumulative experience of a doctor includes cumulative experience of the profession and so for many things his actions are amenable to peer judgment. So a doctor can’t be law unto himself.
    No doubt medical care has to be customized, but in plethora of situations I encounter in my medical practice, I have to go by cumulative experience of the profession with a layer of my own experience and practices. So customization for individual patients is generally not feasible or possible.
    So the difficulties highlighted in this article are slightly blown out of proportion.

  • khmd

    I agree and sympathize with your situations. This stuff happens all the time. Obviously you are a doctor that is personally hurt when you can’t give your patients the care you think they need.
    I want to give the best care possible, but if we aren’t going to be allowed to give what we feel is the best care, we shouldn’t be held to the standard of giving the “best care possible”. It is a complete double standard. If there just isn’t money for the best care, let’s be transparent and let the general public know that the best care is not available to most unless they elect to pay out of pocket for it (Of course this is not possible for most. We all know what state the economy is in).
    And please don’t sue medical professionals when something goes wrong because we had to use the algorithm that was dictated to us by the federal government. Very disappointed that Obamacare managed to write War and Peace on medical policy and conveniently left tort reform out of medical-economical reform. Defensive wasteful medicine still reigns supreme while some kid can’t get the medication he/she needs to breathe.

  • LBENT

    Most pharmacists do not become engaged in this process, in my experience. They tell the patients it is up to our offices.
    You make an assumption that all doctors leap to the most expensive medicine or treatment. That is simply not true. Most try to stay current. Perhaps if direct marketing to patients would stop, we would not be told that someone wants this pill or that because they heard it was better on TV.

    Sometimes there are reasons to go to maximum medical therapy (like a life threatening airway problem) which I see reasonably often. This is very hard to tell the nurse on the line from the insurance company when they don’t even know the name of the problem you are treating.

    We don’t have unlimited resources. But to waste our resources on this nonsense is, well, nonsensical. AND, the outcomes studies (of which I have done quite a few) don’t always support the algorithms devised. In fact, they rarely do. And sometimes these algorithms cause harm, as was written in the Hartzband and Groopman editorial.

  • Sue McIntire

    Guess Congress should have let the Physicians for National Health Program speak instead of arresting them and throwing them in jail when they asked why Single Payer was not on the table. As long as the insurance CEO’s are making a profit off sick people, they will be in control. Medical care should be between the Provider and the Patient.
    PNHP.ORG

    • LBENT

      I agree. The third party is just that a third, largely disruptive, party.

  • meyati

    I’d be happy for a few things-very few—-That Medicare and my HMO pharmacy board recognizes that synthetic thyroid replacement hormones make me ill- do not work. I got a letter that I couldn’t take Armour any more-do these jerks really think that somehow my physician and I are in a 1960 time warp when it comes to thyroid?

    The second thing is that pharmacists don’t lie to me–My doctor prescribed 10 mg of antihistamine. I took it -fine-I needed a refill. The pharmacy said they were out-and asked me how long could I last—They told me that the new med was the same med in a different shape. The old company didn’t properly label the med, etc. Why do these things happen on a Fri. night or Sat? I had a thyroid storm. I called the manufacturor and they told me ask “Why does the med have a warning for thyroid. I did. Response by the pharmacist-THYROID DOESN’T MEAN ANYTHING- Then the original pharmacy didn’t move my allergies to the HMO file-and dispensed a drug that I’m allergic to. When I got well-I took the bottle over and asked them what was on my allergy list. -Tylenol- Why did you sell me this? Are you waiting for people to die? I AM NOT HAPPY WITH PHARMACISTS IN THIS AREA-THEY NEED TO UPDATE FILES, THEY NEED TO TELL THE TRUTH TO A PATIENT. IS THAT TOO MUCH TO ASK? AND THE STUPID BOARDS SHOULD CONSIDER-IS THIS MEDICATION KEEPING THE PATIENT OUT OF THE ER? IS IT WORKING?

  • Robert Luedecke

    I empathize with your frustration. Unfortunately practicing medicine without cost constraints is not sustainable. The time is here when either we help decrease the cost of care or the insurance companies will take that cost out of our payment. It can be darn inconvenient, but we can either continue to rail against the fact that medical care in the US is too expensive or we can help do everything we can to decrease that cost. This problem has nothing to do with the passage of Obamacare.